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Predicting the need for subclavian artery revascularization in thoracic endovascular aortic repair: A systematic
Tariq Alanezi1, Abdulmajeed Altoijry2, Sultan AlSheikh2
1College of Medicine, King Saud University, Riyadh, Saudi Arabia.
Insights
Left subclavian artery revascularization during thoracic endovascular aortic repair reduces stroke and spinal cord ischemia risks. However, it does not affect mortality, and increases reintervention rates, guiding clinical decisions.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Thoracic Surgery
Background:
- Thoracic endovascular aortic repair (TEVAR) is a minimally invasive treatment for thoracic aortic aneurysms and dissections.
- The left subclavian artery (LSA) is often covered during TEVAR, raising concerns about potential complications.
- Revascularization of the LSA is a strategy to mitigate these risks, but its overall benefit remains debated.
Purpose of the Study:
- To systematically review and meta-analyze the effectiveness of LSA revascularization versus non-revascularization in TEVAR.
- To summarize current evidence on the indications for LSA revascularization.
- To evaluate the impact of LSA revascularization on peri-procedural complications and long-term outcomes.
Main Methods:
- A comprehensive search of major databases (MEDLINE, SCOPUS, Cochrane Library, Web of Science) was performed up to November 2023.
- Two independent reviewers selected studies, abstracted data, and assessed quality using the Newcastle-Ottawa Scale.
- Random-effects models were used to calculate pooled odds ratios (ORs) with 95% confidence intervals (CIs) for various outcomes.
Main Results:
- LSA revascularization was associated with significantly reduced risks of stroke (OR, 0.67), spinal cord ischemia (OR, 0.75), and arm ischemia (OR, 0.09).
- No significant reduction in paraplegia or mortality was observed. The risk of reintervention was higher in the revascularization group (OR, 1.98).
- Indications for LSA revascularization included primary prevention of spinal cord ischemia, landing zone augmentation, and stroke prevention.
Conclusions:
- LSA revascularization in TEVAR reduces neurological complications but does not impact mortality.
- The study identifies key indications for LSA revascularization and predictors of complications.
- Findings provide evidence to support clinical decision-making regarding LSA management during TEVAR.
Objective:
This systematic review and meta-analysis aims to investigate the effectiveness of left subclavian artery revascularization compared with non-revascularization in thoracic endovascular aortic repair, and to summarize the current evidence on its indications.
Methods:
A computerized search was conducted across multiple databases, including MEDLINE, SCOPUS, Cochrane Library, and Web of Science, for studies published up to November 2023. Study selection, data abstraction, and quality assessment (using the Newcastle-Ottawa Scale) were independently conducted by two reviewers, with a third author resolving discrepancies. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using random-effects models and publication bias was assessed using funnel plots.
Results:
In the 76 included studies, left subclavian artery revascularization was associated with reduced risks of stroke (OR, 0.67; 95% CI, 0.45-0.98; n = 15,331), spinal cord ischemia (OR, 0.75; 95% CI, 0.56-0.99; n = 11,995), and arm ischemia (OR, 0.09; 95% CI, 0.01-0.59; n = 8438). No significant reduction in paraplegia (OR, 0.56; 95% CI, 0.21-1.47; n = 1802) or mortality (OR, 0.77; 95% CI, 0.53-1.12; n = 11,831) was observed. Moreover, the risk of endoleak was comparable in both groups (OR, 1.25; 95% CI, 0.55-2.84; P = .60; n = 793), whereas the risk of reintervention was significantly higher in the revascularization group (OR, 1.98; 95% CI, 1.03-3.83; P = .04; n = 272). Both groups had similar risks of major (OR, 0.45; 95% CI, 0.19-1.09; P = .08; n = 1113), minor (OR, 0.21; 95% CI, 0.01-3.45; P = .27; n = 183), renal (OR, 0.61; 95% CI, 0.12-3.06; P = .55; n = 310), and pulmonary (OR, 0.59; 95% CI, 0.16-2.15; P = .42; n = 8083) complications. The most frequent indications for left subclavian artery revascularization were primary prevention of spinal cord ischemia, augmentation of the landing zone, and primary stroke prevention.
Conclusions:
Left subclavian artery revascularization in thoracic endovascular aortic repair was associated with reduced neurological complications but was not found to impact mortality. The study highlights important indications for revascularization as well as significant predictors of complications, providing a basis for clinical decision-making and future research.
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